Richard Graham, Chair of the Northern Ireland Dental Practice committee outlines the evidence he presented to the Assembly Health Committee on the support all practices across Northern Ireland urgently need in order to keep Health Service dentistry viable.
Since March, dentists across Northern Ireland have risen to the challenges presented by the COVID-19 crisis and have proven time and again what a fundamental service they provide. Today I presented evidence of this to the Northern Ireland Assembly Health Committee and pressed for urgent support to help our dental service avoid a catastrophe. You can watch the Assembly Health Committee and hear my presentation here (I start at 2 hrs 12min).
Here is a summary of the case I put forward.
Dentists going above and beyond
When routine dentistry was suspended and practitioners were instructed to cease all aerosol generating procedures (AGPs), we rapidly moved to a situation of emergency and urgent care only, and urgent dental centres (UDCs) were quickly established.
However, it is important to stress that dental practices remained open throughout the pandemic. They were fundamental to providing patients, even those unregistered, with telephone triage, the three As (advice, analgesia and antimicrobials), and referrals to UDCs.
In fact, there has been more collaboration across the range of services in these past months in maintaining a level of patient care than perhaps ever before. Dentists donated their PPE and oxygen cylinders, redeployed to apply their considerable knowledge of infection control, and worked in community pharmacies and care homes. They truly stepped up to show time and again what an essential role dentists have in maintaining public healthcare.
In setting up the UDCs, the Community Dental Service worked tirelessly alongside the GDS, hospital dentistry and the CDO, Michael Donaldson, to rapidly equip Northern Ireland with five centres. They must be commended for this sterling work.
"The feeling that the profession is often the last in line damages morale and goodwill within the profession."
And yet, community dentists who have worked those longer hours, on the frontline in care home and other settings still await confirmation they will be paid. The Department has taken months to confirm a temporary regional rate of pay. This follows on from dentists still waiting to receive their pay uplift for 19/20.
The feeling that the profession is often the last in line damages morale and goodwill within the profession. Dentists need support and a conversation must start urgently on finding a new way to restore confidence in the sector.
The future of Northern Ireland dentistry
As dental practices return to provide non-urgent care later this month, we continue to raise our concerns and press for change in the following areas.
1. Helping practices to obtain PPE
After the timeline for the phased recovery of dental services was announced last week, we welcomed the CDO’s confirmation that he is working alongside officials in the Department of Health to agree how personal protective equipment (PPE) will be provided to dental teams across Northern Ireland.
This support is essential to the viability of practices. A colleague of mine has calculated that they will be spending £120 per day on masks. Another has said that it will cost him £11.29 for a small filling on a back tooth when he’s paid £9.39 to carry it out. These are unfeasible numbers.
Now that the clock for re-establishing services is ticking, the profession urgently needs clarity on what financial support/access to PPE will be made available as they seek to be ready.
2. Financial support after August
Looking ahead, we remain extremely concerned at what could happen after August, particularly as the Department has fired warning shots that future support will have to be ‘subject to the confines of the dental budget’.
"The issue is that as long as COVID restrictions are with us, dental practices will be unable to return to normal activity"
The issue is that as long as COVID restrictions are with us, dental practices will be unable to return to normal activity levels. A return to an Item of service activity-based contract model, without continuation of government support, would decimate dental practices, and with it the future of health care dentistry in the GDS.
At this time of great uncertainty and anxiety, rather than alarming practitioners with talk of budget constraints, there is an onus on DoH to give general practitioners the assurance that they will do whatever it takes to get them, and in turn Health Service dentistry, through this crisis intact.
We also call for DoH to initiate a genuine conversation about the shape of the GDS remuneration model that will apply from September on.
3. Financial support and maternity
Not all practitioners have benefitted equally. Under Phase 1 of FSS, we know of 26 female dentists who, because of maternity leave during the 18/19 reference period have received payments they feel are considerably lower than had they not been off on maternity.
Those practitioners have been left feeling disadvantaged, discriminated against even, and as yet, the majority of these cases remain unresolved.
This issue requires a resolution, and quickly.
4. Re-thinking dental services
We believe there is an opportunity to use the COVID experience for a radical re-think of dental services here.
Rather than a system that is treatment-based and essentially pays for failure, we could take the opportunity to design a model that delivers oral health improvements. That would mean moving beyond an approach that ‘counts widgets’, to free up practitioners to apply their skills to improve oral health outcomes. This would apply effective prevention across the life course and depart from an outdated, decades old, activity-based system.
"The vision that we have would require an updated policy framework that is based on prevention, as opposed to treatment" The vision that we have would require an updated policy framework that is based on prevention, as opposed to treatment. We’ve been calling for a new oral health strategy for years. With the rebuild of HSC services post-COVID, now is our chance. The BDA is committed to working with all stakeholders on this, especially the Acting CDO, practitioners, academics and policymakers.
This new departure would also require adequate representation of dentistry at a senior level within the Department of Health. That must include the Acting CDO having a seat at the new Management Board being established. This ensures that dentistry is both represented and its particular issues and scale factored into the important task ahead of rebuilding HSC services.
As we look ahead, we are concerned that the oral health of the elderly, particularly those living in care homes and shielding, will deteriorate considerably during the crisis. We remain concerned that waiting lists for child GA extractions have soared upwards, and that we do not yet have a regional solution in place to deal with this.
We are concerned that referrals for urgent head and neck cancer follow-up has reduced by approximately 50% and other specialist hospital dental services are currently unavailable to the patients who need them most. The most vulnerable in society will be affected the most, widening existing inequalities and reducing quality of life.
5. Prioritising oral health
"Our challenge to the Department is to take the necessary steps to prioritise dentistry in the rebuild."
More than ever, oral health matters. Years of raiding the GDS budget for other priorities (a £6.8m surplus/underspend in General Dental Services in 19/20 alone, or £19.1m over five years 2015/16 -19/20), deprioritising oral health, overlooking oral health’s importance to general health, and undervaluing the immense contribution our dentists make within HSC, has got to come to an end.
Health Service dentistry and General, Community, and Hospital Dental Services must feature prominently in the HSC Rebuilding plans. We have an opportunity to do things differently and better.
Members will know that the dental profession has been left to fight for its very survival over the past months. Our challenge to the Department is to take the necessary steps to prioritise dentistry in the rebuild.
Do not remove funding at this time of need. Include us as willing partners as we seek to collaborate in turning adversity into an opportunity to improve oral health.
Chair of the Northern Ireland Dental Practice committee